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San Antonio APIC

San Antonio APIC. March 2011 The Joint Commission Survey Process Overview. AGENDA. TJC Survey Process (hospitals) TJC Chapter Requirements Periodic Performance Review (PPR) Survey Readiness Infection Control & Prevention Chapter Resources Discussion & Questions. OBJECTIVES.

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San Antonio APIC

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  1. San Antonio APIC March 2011 The Joint Commission Survey Process Overview

  2. AGENDA • TJC Survey Process (hospitals) • TJC Chapter Requirements • Periodic Performance Review (PPR) • Survey Readiness • Infection Control & Prevention Chapter • Resources • Discussion & Questions

  3. OBJECTIVES • Provide an overview of TJC Survey Process (hospitals) • Review the TJC Chapter Requirements & Infection Control & Prevention Chapter • Discuss Periodic Performance Review (PPR) & Survey Readiness • Share TJC Survey Related Resources

  4. TJC SURVEY PROCESS • Unannounced Survey Process • Posted on TJC secure extranet site by 7:30 a.m. • Survey window – 18 to 39 months after previous full survey • Strategic Surveillance System (S3- past survey findings, ORYX® core measure data, data from the Office of Quality Monitoring (complaints and non-self reported sentinel events), data from an organization’s electronic application, and HCAHPS data. • TJC Survey Team Composition (based on size & complexity of your organization) -> Lead Surveyor, Administrator, Nurse, Generalist, Specialist (e.g. lab), Life Safety Code Specialist

  5. TJC SURVEY PROCESS • Opening Session (Leadership)– survey overview & orientation to organization • Document Review – Policies, Plans, Meeting Minutes, Census • Individual Tracer Activity– Isolation Patient, Surgical Patient • System Tracers – depends on the size/complexity of your organization • Infection Control & Prevention • Medication Management • Data Use • Program Specific Tracers – suicide prevention, patient flow, lab integration • Competency & Medical Staff Credentialing & Privileging

  6. TJC SURVEY PROCESS • Infection Control & Prevention System Tracer • Composition of Team (IC members -> Employee Health, Pharmacy, Lab, EVS, Facilities Management, Nursing, Procedure Areas) • Scheduled after Document Review & Individual Tracers • Discussion - review of accomplishments and opportunities • Exit Briefing & Exit Summary - “Summary of Survey Findings Report” • Direct Impact Standards • Condition of Participation Deficiencies -> Central Office Review • Indirect Impact Standards

  7. Infection Control & Prevention System Tracer • IP Program Assessment & Plan • Population Demographics  Annual Plan • MDROs -> Lab (culture result tracking), Pharmacy, Dietary, EVS, NPSG, tracking • SSIs -> Health Optimization Prior to Elective Surgery, types of procedures monitored, Joint, Cardiac and Bariatric Surgery • Device Related Infections -> CLABSI, VAP, CAUTI • Review of a patient in isolation as a table top tracer • Type of isolation • Education of staff, patient, visitors • Tracking & Notification

  8. TJC SURVEY PROCESS • Potential Accreditation Decision – “Accreditation Survey Findings Report” posted on secure extranet site includes the potential accreditation decision (within 2 days usually) • Central Office Review – COP, Immediate Threat, Situational Decision Rules • Final Accreditation Decision – Evidence Standards Compliance (ESC) • Immediate Threat to Health or Safety • Situational Decision Rules • Direct Impact Standards (45 days) • Indirect Impact Standards (65 days) • MOS – 4 months

  9. Continuum of survey activity outcomes Reports that meet a decision rule that automatically triggers a PDA, Cont or AFS or a report with a CMS Condition level or APR deficiency will be reviewed by TJC Central Office. Reminder: CMS conducting validation surveys

  10. TJC CHAPTER REQUIREMENTS • Chapter – NPSG, EC, EM, HR, IC, LD, MS,PI,TS • Standard (Requirement) – statements that define the performance expectations and/or structures or processes • Rational – background, justification, additional information • Element of Performance (EP) – identify performance expectations • References – help to identify related standards/EPs • Icons

  11. TJC CHAPTER REQUIREMENTS • Numbering Requirements • Standard six digit number broken down into three sets of two numbers each • For Example, IC.02.04.01 • First two letters are the chapter acronym • First two digits refer to the Roman numeral in the outline • Second two digits refer to the letter under the Roman numeral in the outline • Last two digits refer to the standard number

  12. TJC CHAPTER OUTLINE - IC • I. Planning • A. Responsibility (IC.01.01.01) • B. Resources (IC. 01.02.01) • C. Risks (IC.01.03.01) • D. Goals (IC. 01.04.01) • E. Activities (IC. 01.05.01) • F. Influx (IC. 01.06.01) • II. Implementation • A. Activities (IC.02.01.01) • B. Medical Equipment, Devices, and Supplies (IC.02.02.01) • C. Transmission of Infection (IC. 02.04.01) • III. Evaluation and Implementation (IC. 03.01.01)

  13. TJC Glossary of Terms What is the time line for resolution of non-compliant findings? What is the immediacy of risk to the patient? Short High Low Long

  14. Example – Scoring and Icons Scoring Category Documentation Scoring Scale Criticality Tag 3 MOS

  15. TJC Periodic Performance Review • Tool for self-assessing compliance with standards and requirements between on-site surveys • Process to identify potential areas of concern, and opportunities to make ongoing adjustments.

  16. PERIODIC PERFORMANCE REVIEW • Organization’s self assessment with chapters, standards and EPs • Noncompliant Standard – Plan of Action(POA); Measure of Success (MOS) • Completed annually one year after survey • Several Options for submission • Full PPR and 3 other options

  17. PERIODIC PERFORMANCE REVIEW Review using resources Questions: Contact Facility Administrator

  18. TJC Survey Readiness • PPR – self assessment & POAs/MOS • Mock Individual/Patient, Progam Tracers – IP and Team • Infection Prevention & Control related examples • Isolation Patient Tracers – MDRO’s, Precautions • Surgical Patient • Instrument handling and reprocessing • Biohazard Waste • Food and Nutrition Services • Environment of Care • Practice Infection Control System Tracer

  19. TJC Survey Readiness

  20. Infection Control & Prevention Chapter Summary - Planning • IC.01.01.01 – Identifies individual(s) responsible for program • IC.01.02.01 – Leaders allocate needed resources for program • IC.01.03.01 – Hospital identifies risks for acquiring and transmitting infections • IC. 01.04.01 – Based upon risks hospital sets goals to minimize possibility of transmitting infection • IC. 01.05.01 – Hospital has an IP and Control Plan • IC. 01.06.01 – Hospital prepares to respond to an influx of potentially infectious patients

  21. Infection Control & Prevention Chapter Summary - Implementation • IC.02.01.01 – Hospital implements its IP and Control program • IC.02.02.01 – Hospital reduces the risk of infections associated with medical equipment, devices, and supplies • IC.02.03.01 – Hospital works to prevent transmission among patients, LIPs and staff • IC. 02.04.01 – Hospital offers vaccination against influenza to LIPs and staff

  22. Infection Control & Prevention Chapter Summary – Evaluation & Improvement • IC.03.01.01 – Hospital evaluates the effectiveness of its IP and Control Plan

  23. National Patient Safety Goals • Goal 7 – Reduce the risk of health-care associated infections • Meeting Hand Hygiene Guidelines • Preventing MDRO’s • Preventing CLABSI • Preventing SSI 2012 – VAPs and CAUTI • Sentinel Events – separate chapter

  24. 2010 Challenging Standards - IC • Identify risks for acquiring/transmitting infection. IC.01.02.01/EP#1&2 (Identify & prioritize risks based on location, community, and services provided) • Reduce the risk of infections associated with medical equipment, devices, supplies. • IC.02.02.01/EPs #1,#2, #4 (Implement infection prevention and control activities when cleaning, performing disinfection, sterilizing, and storing) {DIRECT IMPACT}

  25. Resources Available • JCR & TJC Publications – Perspectives • Infection Prevention & Control Publications • TJC Hospital E-dition 2011 (updated July and before January) • TJC website (www.jointcommission.org/Standards/FAQs) • BoosterPak • R3 Report • TJC Leading Practice Library • Joint Commission Center for Transforming Healthcare (www.centerfortransforminghealthcare.org/) • IP Networking

  26. TJC BoosterPak(As of January 2011 two BoosterPaks Published) Full version available on HITT site.

  27. R3 Report (As of January 2011 One Report Published)

  28. Leading Practice Library

  29. Leading Practice Library

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